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Abstract

Osteopathic medicine is strongly identified with primary care. In the past 20 years, several factors have influenced this relationship, resulting in significant changes in the postdoctoral training of doctors of osteopathic medicine (DOs). Growth in colleges of osteopathic medicine spilled over into postdoctoral programs of the Accreditation Council for Graduate Medical Education (ACGME), creating a number of consequences. More than ever, osteopathic physicians are filling voids in ACGME primary care residency positions left vacant by U.S. medical graduates. Many allopathic primary care residencies have created parallel-accredited (American Osteopathic Association/ACGME) programs in hopes of tapping into this supply of DOs. In turn, osteopathic training institutions have shifted their educational emphasis in support of nonprimary care residencies. As a result of these changes, there is a strong element of irony in the underlying reasons for osteopathic medicine's link to primary care, why osteopathic training institutions are emphasizing specialty residencies, and the new responsibility of allopathic programs in training the next generation of primary care DOs.

Over its history, osteopathic medicine forged a strong identity with the primary care specialties of family medicine, pediatrics, and general internal medicine. Several colleges of osteopathic medicine (COMs) include in their mission statements the goal to produce primary care physicians. The American Osteopathic Association (AOA) promotes the concept that its doctors provide a holistic approach to patient care emphasizing primary care combined with additional skills in musculoskeletal medicine.1 As propagated, these distinguishing characteristics differentiate doctors of osteopathic medicine (DOs) from allopathic physicians (MDs). The link between osteopathic medicine and primary care is strongly supported by past and current AOA members who identify themselves as primary care doctors. Based on a number of various indicators, including the public perception of DOs, there are few who would argue against linking osteopathic physicians with primary care.

For the 20th century, this identity may have been more a matter of circumstance than of choice. By and large, osteopathic physicians had limited numbers of training institutions and, until recently, few opportunities in programs of the Accreditation Council for Graduate Medical Education (ACGME). For most of the last century, the common pattern followed by many DOs was to complete medical school, take a one-year rotating internship, and then go directly into medical practice, largely in a rural or urban community as a general practitioner. The name of the largest medical society, the American College of General Practitioners (changed in March 1993 to the American College of Osteopathic Family Physicians) reflected the character of those physicians who followed this educational path.2 With limited opportunities, the majority of osteopathic physicians were funneled into careers in primary care medicine, since they had few options to choose other medical specialties.

A number of forces coalesced in the 1990s that changed the landscape for osteopathic medical education. One factor was the impact of rapid expansion of new COMs and medical students. The number of COM graduates was 1,151 in 1980, 1,534 in 1990, and 2,628 in 2003.3,4 A second important development was the growing demand that physicians, both allopathic and osteopathic, be residency trained to participate in managed care programs and to obtain hospital privileges. It was no longer an option for osteopathic physicians to enter medical practice after the one-year internship program. Occurring at the same time, a third trend witnessed the rapid expansion in the number of ACGME residency programs with 61,819 positions filled in 1980, 82,902 in 1990, and 99,964 in 2003.5,6 Yet the number of graduates from Liaison Committee on Medical Education-accredited medical schools remained largely unchanged.7 Finally, osteopathic training institutions were in a state of retrenchment and could not keep pace with the increased student population and provide for their postdoctoral needs.

Osteopathic Physicians' Migration to Allopathic Programs

The confluence of these trends generated new patterns in medical education for osteopathic physicians, who turned more and more to ACGME programs for postdoctoral training. In 1985, for example, there were 1,277 DOs in ACGME-accredited residency programs; in 2003, there were 5,838.5,6 In the 2005 National Resident Matching Program (NRMP), 642 (61%) of the 1,045 DOs matched to PGY-1 primary care specialties.8 New opportunities for absorption into ACGME programs were the direct result of the national growth in the supply of residency positions and the demand for qualified candidates.

DOs seeking training in ACGME programs once again found themselves steered towards primary care specialties. These specialties were the most receptive in accepting osteopathic physicians because the supply of U.S. medical graduates (USMG) did not fill all of the available open positions. In fact, in recent years USMGs have demonstrated a stronger preference for non-primary-care specialties, and that has helped to make osteopathic physicians more attractive in filling this void. Relatively few DOs can be found in ACGME surgical residencies, where competition for selection is quite keen and USMGs are favored. For example, 13 DOs were training in allopathic otolaryngology programs in 1987 and only 12 in 2003; for orthopedic surgery the numbers were 15 osteopathic physicians in 1987 and 18 in 2003.5,6 These and other competitive allopathic residencies are almost all filled by USMGs. Some other specialties, however, have become more accepting of DOs into ACGME programs, including anesthesiology, emergency medicine, obstetrics–gynecology, physical medicine and rehabilitation, and psychiatry. It is more than coincidence that these specialties, save emergency medicine, also match with a comparatively high percent of international medical graduates.6 Overall, the pattern of DOs entering the ACGME system chiefly in primary care specialties reinforces the link between osteopathic physicians and primary care.

Allopathic Crossover to AOA Accreditation

The shift of DOs gravitating to ACGME programs for primary care training has been gradual and consistent over the past 15 years. In 1987, osteopathic physicians filled 523 (32%) AOA-accredited primary care residency positions and 1,114 ACGME primary care slots.9 Most recent data for 2003 report, for primary care, 855 (23%) of DOs in AOA programs and 2,923 in ACGME residencies.3,6 Within the ACGME, the total number of residency positions increased since 2000, yet the number of offered positions in family and internal medicine declined. The percent of unfilled positions increased as well. In the 2005 NRMP, for example, close to one in every five (17.6%) available ACGME family medicine residency positions went unfilled.10

One response of allopathic primary care program directors has been to aggressively pursue osteopathic physicians by obtaining AOA accreditation of their existing ACGME program, especially in family medicine and pediatrics. Presently, 11 of the 15 AOA programs in pediatrics are also accredited by the ACGME.11 As of May 2004, 44 of the 472 (9%) ACGME-accredited family medicine residencies have acquired AOA internship and family medicine accreditation as well.12 The intent of creating parallel-accredited programs is to graft an osteopathic component onto an ACGME program and to establish a direct pipeline for osteopathic students to take all their postdoctoral training with AOA approval. By and large, minor curricular adjustments are required to accommodate osteopathic accreditation while the essential characteristics of the allopathic program change little if at all.

The actual number of ACGME family medicine programs with AOA internship accreditation is considerably higher than indicated above. The AOA accredits internship and residency programs separately, and many ACGME family practice programs pursued the strategy of becoming accredited to train osteopathic interns only. In so doing, the first year of postdoctoral training is approved as an AOA internship and as a first-year residency on the ACGME side. The expectation is that DOs in these internship only programs will continue into the second and third years of the allopathic residency without osteopathic accreditation being obtained for the ACGME family medicine program. Between 2000 and 2003, the AOA approved 97 new internship programs of which 71 (73%) became AOA/ACGME accredited.13 This large influx of ACGME-accredited programs applying only for internship approval prompted the AOA to change its standards in October 2003 to require that all AOA/ACGME internship programs must apply for at least one AOA-accredited residency program in combination with the internship program within a two-year period.14 This policy was implemented to allay fears that existing osteopathic residency programs faced uneven competition in recruiting osteopathic residents and to ensure that all osteopathic graduates of parallel-accredited programs become eligible to take osteopathic certifying board examinations upon completion of training. As a result of this new requirement, the number of ACGME family medicine programs applying for AOA accreditation for their residency is expected to grow rapidly.

Impact on Osteopathic Training Institutions

Osteopathic training institutions with AOA-only accredited programs face a number of stern challenges. As more COM graduates opt for ACGME and AOA/ACGME programs, gaping fissures appear in the primary care foundations that had been their core. In 2003, the AOA reported only 580 (36%) of its approved 1,596 family medicine and 246 (40%) of 616 internal medicine positions were filled—numbers inclusive of parallel-accredited programs.3 By comparison, in 1998 and with relatively few parallel-accredited programs, 1,109 (77%) of 1,448 family practice positions had osteopathic residents in place.15 The loss of primary care residents in osteopathic training institutions has been swift and profound.

Results of an AOA survey published in January 2001 reported that the three leading reasons why osteopathic graduates choose ACGME and AOA/ACGME residencies over AOA-only accredited programs were perceived differences in educational quality, institutional reputation, and the geographical diversity of allopathic programs.16 Stemming from its origins, osteopathic postdoctoral programs are concentrated in the Midwest and Pennsylvania. By contrast, the newest osteopathic COMs are located in regions lacking a base of osteopathic postdoctoral programs. Other private COMs with large class sizes now train many of their third- and fourth-year students at allopathic sites. Students at these COMs receive much of their clinical education at institutions that have ACGME and/or AOA/ACGME programs. It is not surprising, therefore, that graduates of these COMs are less likely to relocate and select AOA-only accredited programs when ample allopathic opportunities in primary care exist locally.

With large numbers of vacant primary care positions, osteopathic training institutions also contend with the rolling three-year average provision of the Balanced Budget Act of 1997. They face reduced levels of federal support for their postdoctoral programs if residency positions remain consistently unfilled. The response of the osteopathic training institutions has been to expand existing or generate new non-primary care residency programs, especially those where DOs have limited opportunities in ACGME programs. In 2003, the AOA reported 114 more residents training in emergency medicine (360) than in internal medicine (246) and more than double the number of DOs training in AOA-approved programs in otolaryngology residencies than in pediatrics (29). Collectively, the five specialties of emergency medicine, obstetrics/gynecology, orthopedic surgery, otolaryngology, and general surgery in 2003 constitute 43% of all DOs training in AOA-accredited programs compared with 15% of DOs in ACGME programs.3 Michigan has the largest number of osteopathic training institutions and residents in training. Between 2000 and 2004, the number of residents in primary care fell from 368 to 262 while the non-primary care residents jumped from 500 to 630.17 Specialty programs are in high demand among DO graduates and osteopathic training institutions have the advantage of a near monopoly. Converting unfilled primary care positions to popular specialty residency slots preserve the Centers for Medicare and Medicaid Services cap number from involuntary reductions and lost revenue streams. As primary care medical education gradually moves away, osteopathic training institutions are becoming centers of specialty training of osteopathic physicians in disciplines where head-to-head competition with ACGME-accredited programs does not occur.

Conclusions

Developments in osteopathic medical education have produced more than their share of irony. The osteopathic profession touts its emphasis on primary care medicine, yet the overwhelming amount of this medical education is provided in allopathic environments and not at osteopathic training institutions. Whether or not DOs are truly interested in primary care disciplines itself cannot be determined. With a surfeit of osteopathic physicians, educational opportunities in ACGME programs are chiefly in primary care and less competitive residencies where DOs backfill open positions caused by USMGs' preferences for specialty programs.

Allopathic primary care program directors are obtaining AOA accreditation as a popular strategy to fill vacant positions and are looking at DOs as an important source of resident manpower. In the current environment, mutual need and open competition have brought the osteopathic and allopathic professions into closer working relationships but on a less-than-firm foundation. All it takes is a sudden upswing in USMGs choosing primary care residencies to alter the precarious balance of mutual dependency and need. On the other hand, the osteopathic profession is in the unenviable position of coping with unprecedented growth, having a limited number of osteopathic training institutions, and no alternative other than ACGME programs for the postdoctoral training of their graduates. It is ironic that many allopathic primary care program directors are actively pursuing AOA accreditation to gain an advantage when this step is not necessary to attract DOs.

Osteopathic training institutions are generally community-based hospitals of small to medium size that are ideal locations to train primary care doctors. The irony here is that faced with increased competition by ACGME primary care programs, these osteopathic training institutions are retreating from primary care. Instead, they have created or expanded specialty residency programs in efforts to recruit osteopathic physicians, avoid decreased federal funding, and provide training opportunities in ACGME specialty residencies that do not accept DOs in large numbers. In the eyes of students, osteopathic training institutions are more valued and attractive for their specialty residencies than for contributions in primary care. These hospitals enjoy a dominating position in many surgical specialties and represent the only training option for osteopathic physicians interested in many disciplines.

The final irony is that the growth in COMs and graduating class size will have only the effect of reducing career options for DOs outside of primary care. The impact of too many osteopathic physicians for too few specialty positions will continue unless competitive ACGME residencies begin selecting more DOs over USMGs and/or the declining number of osteopathic training institutions finds ways to continually expand specialty residencies to meet the demand. The likely outlook for the near future is that osteopathic physicians will discover that their greatest opportunity for residency training is in the least competitive of ACGME programs, namely, primary care. As a result, the identity of osteopathic medicine as primary care will continue, with the interesting twist that allopathic physicians, and not osteopathic physicians, will play a major role in shaping the postdoctoral formation of future DOs.

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